1. Field of the Invention
The present invention relates to the cost effective use of prescription medications, and more particularly to a computerized system and method for dynamically adjusting patient copayments for medications based upon clinical circumstances and patient attributes.
2. Description of the Related Art
Physicians are currently inundated and overwhelmed with guidelines for the most appropriate or cost-effective use of medication therapy based upon a patient's medical history. In one example, for the treatment of an uncomplicated middle ear infection in a young child who is otherwise healthy, there is strong evidence that certain inexpensive generic antibiotics are just as effective yet far cheaper than expensive brand-name medications, and equally safe. Unfortunately, there are currently about 7,500 medical journal articles published per week, and it has become humanly impossible for medical doctors to keep abreast of the latest developments to ensure optimal and/or the most cost-effective care for their patients. However, cost-effective use of medications will be imperative in the future, as drug-related expenditures are increasing at an unsustainable rate, and constitute the largest component of increasing healthcare costs overall.
The problem in adhering to guidelines for the cost-effective use of medications is not one of negligence or disregard by the physician, but sheer information overload. Many studies by sources such as the American Medical Association have demonstrated that letters to doctors, faxes, and articles in journals are largely ineffective at reducing inappropriate use of medications because medical doctors generally do not have the time to read or absorb them. Content delivery, whether by paper, Internet, or hand held computers such as Personal Digital Assistants (PDA's), is not likely to solve this problem because there is no time to search for, read, and retain the information provided, regardless of the method of delivery.
Electronic medical records (EMRs) are becoming widely used by hospitals and medical care facilities, where a patient's medical conditions and attributes are stored in an electronic format. In a patient's electronic medical record, patient characteristics such as diseases, medications, age, laboratory results, and sex are stored in a structured data format. The use of standard catalogs for medical terms in patient electronic records makes the implementation of an electronic medical records system possible and efficient. The US Health and Human Services has recently issued a press release that it will adopt one such catalog, the Systematic Nomenclature of Medicine (SnoMed), as a universal standard for this purpose, and provide it free of charge to all electronic medical record vendors. In this system, virtually all medical terms, including diseases, physical findings, lab abnormalities, etc., have a unique numerical ID associated with each of them. Hence, it becomes possible to algorithmically compare a patient's attributes against a set of guidelines for best practices by determining which patient condition ID values match similar ID values found within the guidelines.
Universal methods for real-time data interchange, such as the wireless Internet, can provide physicians with access to the patient electronic record and clinical guidelines at the point of care, in addition to important economic variables such as which medications are covered by a patient's insurance plan (also referred to as a formulary). Furthermore, for each medication covered by a patient's insurance carrier, or listed on the insurer's formulary, a physician can be immediately informed as to the patient cost for that medication, wherein the patient cost is commonly referred to as the copayment, or copay. However, in current medical insurance plans, formularies and copayments are not patient-specific, but more simplistically plan-specific, where copayments are determined based on average patient statistics for a group that may encompass millions of individuals with a high diversity of medical conditions.